Parastomal hernias are likely some of the most challenging hernias facing the general surgeon. Despite their high incidence and ubiquitous nature, there remains very little good evidence on this challenging problem. The European Hernia Society should be congratulated on a very thoughtful and insightful guideline that should help all surgeons dealing with these hernias and should prompt new discussion with policy makers on how these hernias might be treated and prevented.

There are several important points that should be highlighted related to this guideline and should warrant further discussion and research. First, there are several questions that remain unanswered such as the true incidence of parastomal hernias, optimal imaging modalities for diagnosis, the role of watchful waiting as a treatment strategy, and ideal surgical stomal creation techniques to minimize herniation. In regards to parastomal hernia repair, there are also many questions that remain unanswered such as which open repair and mesh is preferred and is there a difference in outcomes between the open and laparoscopic repair. There are, however, some guiding principles that are outlined including not recommending the suture repair or the laparoscopic keyhole technique as these can lead to higher recurrence rates.

Perhaps, the most intriguing and important part of this guideline relates to the use of prophylactic mesh to reduce the incidence of parastomal hernia formation. Since the incidence of parastomal hernia is quite high and these can be very challenging hernias to repair, I think the major focus and effort as described in this guideline should be in parastomal hernia prevention.

I know this guideline will be of use to many surgeons and I hope it inspires us to come together in a collaborative fashion as hernia surgeons to help answer some of these important questions relating to this complex problem. The AHS appreciates the opportunity to review and co-endorse these guidelines and looks forward to collaborating on future guidelines.

Notes

Compliance with ethical standards

Conflict of interest

I have no conflict of interest related to this invited commentary.

Ethical approval

This study design is confirmed to ethical standards.

Human and animal rights

This article does not contain any studies with human participants or animals performed by the author.